Challenges in the delivery of surgical care for head and neck cancer patients in the Hong Kong Special Administrative Region and China.

PURPOSE OF REVIEW: This article aims to explore the ethical dilemmas faced by head and neck surgeons in the Hong Kong Special Administrative Region (HKSAR) and China in the provision of safe, oncological sound and timely care for head and neck cancer patients. RECENT FINDINGS: There is no literature, in particular, in relation to the treatment of head and neck cancer patients and priority setting in head and neck surgery. However, through examining the healthcare provision and sociocultural backgrounds of the HKSAR and China, certain aspects, such as traditional Chinese medicine and medical guan xi (Seeking medical care for personal connections) have been shown to significantly influence the provision of care in China. Medical guan xi facilitates inequity and is problematic in developing a system based on justice, equity, nonmalfeasance and beneficence. In the HKSAR, resource limitations are related to the maldistribution of healthcare between the public and private sectors, resulting in significant time constraints for surgery and oncology care of patients. There is informal application of ethical frameworks for priority setting, however, these have neither been formally supported nor enforced from an administrative level that needs to be addressed. SUMMARY: In the HKSAR, there needs to be a strengthening of an ethical framework for priority setting to adhere to justice for our patients and healthcare providers in treating head and neck cancer patients. In China, priority setting is largely set by sociocultural practices that are endemic, in particular, medical guan xi that is inequitable and needs to be addressed to improve the doctor-patient relationship.

Appeal to the Rule of Rescue in health care: discriminating and not benevolent?

Thirty years of debate have passed since the term "Rule of Rescue" has been introduced into medical ethics. Its main focus was on whether or why medical treatment for acute conditions should have priority over preventive measures irrespective of opportunity costs. Recent contributions, taking account of the widespread reluctance to accept purely efficiency-oriented prioritization approaches, advance another objection: Prioritizing treatment, they hold, discriminates against statistical lives. The reference to opportunity costs has also been renewed in a distinctly ethical fashion: It has been stipulated that favoring help for identifiable lives amounts to a lack of benevolence for one's fellow creatures. The present article argues against both objections. It suggests that the debate's focus on consequences (deaths or severe ill health) should be reoriented by asking which aspects of such states of affairs are actually attributable to a decision maker who judges within a specific situation of choice.

Patients with multiple needs for healthcare and priority to the worse off.

There is a growing body of literature which suggests that decisions about healthcare priority setting should take into account the extent to which patients are worse off. However, such decisions are often based on how badly off patients are with respect to the condition targeted by the treatment whose priority is under consideration (condition-specific severity). In this paper I argue that giving priority to the worse off in terms of condition-specific severity does not reflect the morally relevant sense of being worse off. I conclude that an account of giving priority to the worse off relevant for healthcare priority setting should take into account how badly off patients are when all of their conditions are considered (holistic severity).

Health technology prioritization: which criteria for prioritizing new technologies and what are their relative weights?

OBJECTIVES: To review the criteria and 'other' considerations used internationally for prioritizing new health technologies, and to demonstrate a conjoint-analysis methodology (also known as discrete choice experiments) for deriving relative weights for the criteria. METHODS: We searched the literature for criteria and other considerations for prioritizing new technologies. A convenience sample of 74 respondents completed a conjoint-analysis survey involving criteria related to technologies' 'benefits'. RESULTS: Encompassing 11 countries and the US state of Oregon, we were able to distinguish three main groups of criteria: (a) Need, appropriateness and clinical benefits; (b) Efficiency (including cost-effectiveness); and (c) Equality, solidarity and other ethical or social values. For several countries, the quality of the clinical and economic evidence and factors related to strategic issues and procedural justice respectively are also considered. The criteria and their weights from the conjoint-analysis survey are: 'Lives saved'=0.343, 'Life-prolongation benefits'=0.243, 'Quality-of-life gains'=0.217, a criterion representing the availability of alternative treatments=0.107, and 'Other important social/ethical benefits'=0.087. CONCLUSIONS: The criteria represent a pluralistic combination of needs-based, maximizing and egalitarian principles, and we demonstrated a methodology for deriving the weights for criteria related to technologies' 'benefits'.

The role of government and competing priorities in minority populations and developing nations.

OBJECTIVE: The purpose of this article is to analyze the role of governments in relation to the burden of chronic diseases and the potential response within the framework of competing priorities that determine resource allocation. METHODS: The following variables were analyzed both in retrospect and prospectively: the epidemiologic transition and the current effect of degenerative chronic diseases, the epidemic of diabetes and kidney disease in minority populations and developing countries, the potential response from healthcare systems, the relationship of chronic kidney disease vs quality of life and costs, and the differences between developed and developing countries. RESULTS: In Latin America, as in many other regions, cardiovascular diseases (ie, heart diseases and stroke) kill many people at early stages of renal disease. Only some survivors have access to renal replacement therapy. Those deaths can be attributed to the lack of systematized prevention and control programs to encompass chronic diseases and relate to poor engineering of adequate financial support. The Latin American Society of Nephrology and Hypertension is fostering a cardiovascular, cerebral, renal, and endocrine-metabolic health program in which 12 countries in the Latin American region implement different strategies, including allocation of national funds and strengthening of transplant programs. The focus of these strategies is on promotion, prevention, rehabilitation, research, and teaching. CONCLUSION: Developing countries should implement cardiovascular, cerebral, renal, and endocrine-metabolic health programs to improve efficiency of sanitary regulations and retrieve the huge amount of money that is spent on illnesses associated with the absence of systematized kidney disease control and follow-up programs.

Priority setting and the ethics of resource allocation within VA healthcare facilities: results of a survey.

BACKGROUND: Setting priorities and the subsequent allocation of resources is a major ethical issue facing healthcare facilities, including the Veterans Health Administration (VHA), the largest integrated healthcare delivery network in the United States. Yet despite the importance of priority setting and its impact on those who receive and those who provide care, we know relatively little about how clinicians and managers view allocation processes within their facilities. PURPOSE: The purpose of this secondary analysis of survey data was to characterize staff members' perceptions regarding the fairness of healthcare ethics practices related to resource allocation in Veterans Administration (VA) facilities. The specific aim of the study was to compare the responses of clinicians, clinician managers, and non-clinician managers with respect to these survey items. METHODS: We utilized a paper and web-based survey and a cross-sectional design of VHA clinicians and managers. Our sample consisted of a purposive stratified sample of 109 managers and a stratified random sample of 269 clinicians employed 20 or more hours per week in one of four VA medical centers. The four medical centers were participating as field sites selected to test the logistics of administering and reporting results of the Integrated Ethics Staff Survey, an assessment tool aimed at characterizing a broad range of ethical practices within a healthcare organization. RESULTS: In general, clinicians were more critical than clinician managers or non-clinician managers of the institutions' allocation processes and of the impact of resource decisions on patient care. Clinicians commonly reported that they did not (a) understand their facility's decision-making processes, (b) receive explanations from management regarding the reasons behind important allocation decisions, or (b) perceive that they were influential in allocation decisions. In addition, clinicians and managers both perceived that education related to the ethics of resource allocation was insufficient and that their facilities could increase their effectiveness in identifying and resolving ethical problems related to resource allocation. CONCLUSION: How well a healthcare facility ensures fairness in the way it allocates its resources across programs and services depends on multiple factors, including awareness by decision makers that setting priorities and allocating resources is a moral enterprise (moral awareness), the availability of a consistent process that includes important stakeholder groups (procedural justice), and concurrence by stakeholders that decisions represent outcomes that fairly balance competing interests and have a positive net effect on the quality of care (distributive justice). In this study, clinicians and managers alike identified the need for improvement in healthcare ethics practices related to resource allocation.

Conflicts of interest in research involving human beings.

Conflicts of interest are inherent to the majority of relationships among individuals and of these with companies and institutions and, certainly, research involving human beings is no exception. In relation to clinical research, the main focus of this manuscript, conflicts of interest occur at different levels and usually permeate among them: In the pharmaceutical industry in their decisions to invest to develop new products, especially vaccines and drugs, and also in relation to marketing of these products; Among the investigators the conflicts may be related to the financial gains to participate in pharma sponsored trials, or to the expected academic career boost attained with the publication of the results of the trials and also to personal interests such as the financial support for trips to international conferences. Often the participation of host country investigators is restricted to performing phase III or IV protocols developed abroad, many times with low scientific relevance, and even lower relevance to public health; Universities or research institutes themselves also have conflicts of interest, as the sponsored projects may help increase their budgets, both directly (taxes) and indirectly (e.g., improvement of physical infrastructure of laboratories or out patient clinics); For the trial volunteers in developing countries, and Brazil is no exception despite free and universal access to its health system, participation in clinical trials is many times seen as, and can really be, an unique opportunity of receiving better health care, better treatment by the health professionals, easier access to costly lab exams and also to receiving certain medications which would otherwise be difficult to have access to. In order to handle these conflicts of interest, Brazil has a well-established and respected legal support and ethical normatization. The latter is represented by Resolution 196/96 of the Brazilian National Research Ethics Committee (CONEP). This national system was established in 1996 providing guidance to all research involving human beings and currently there are approximately 500 local research ethical committees certified by CONEP in all States of Brazil. However, there is intense international pressure mainly from the pharmaceutical industry especially to the ethical requirements emanated from the Declaration of Helsinki (DH), aiming to lower the level of ethical requirements in research to be carried out with volunteers from developing countries. Fallacious reasoning includes that the equity stated at the DH, especially the access to the best proven medical care and to the developed products to all volunteers independently of where the trial is being held, would inflate the costs of research and drive the sponsors away from the developing countries. In this line of thought, if the volunteers have not the same rights that would constitute an unacceptable double standard, or in other words, the best for the volunteers from developed countries and whatever is possible for those in developing countries. This manuscript will focus on the various levels where conflict of interest issues are more prone to happen, such as in the actions of pharmaceutical industries, their relation to health professionals, the participation of universities and research institutes, the ethical research committees and their members, including the possible pressures exerted on them by researchers, sponsors and even their institutions. Emphasis will be given to the interrelation between conflicts of interest and vulnerability, and also the causes and possible solutions to lower the risks of exploitation of volunteers in research. It will also emphasize the need to guarantee access to products that are proven efficacious to all individuals who may need them. Possible ways of empowering these volunteers will be evaluated, so that they become aware of their rights and demand for them. It will discuss the need of separating economic interests from the real needs of public health and of demystifying economic arguments used in order to justify the lowering of ethical requirements. And finally it will address the search for or the establishment of real and effective involvement of all stakeholders in an international organism really representing everyone (e.g., WHO) in order to evaluate, debate, and decrease the risks of several conflicts of interest, aiming at the establishment of research projects that can truly contribute to lower the obscene disparities of health between developed and developing countries.

Priority dilemmas in psoriasis care and visions of a future care in a group of administrators, politicians and professionals in northern Sweden.

During the 1990s priority discussions were actualized in Sweden due to increased demands on health care and limited resources. In the county of Västerbotten in northern Sweden, with large rural areas, the decision makers faced special challenges due to distances and cost. Despite discussions striving for fairness in priorities, decision makers are still dealing with limited resources and difficult priority decisions regarding different diseases and treatments. In this study we aimed at describing views on priorities in public psoriasis care and visions of a future care among politicians, administrators and professionals in the county of Västerbottten in northern Sweden. Qualitative research interviews were performed with 23 key-persons. The findings revealed priority dilemmas about issues on organization, accessibility and ethics. Visions of a future care appeared as ambitions of a more effective care with good accessibility, continued research, information and a holistic approach in priorities. We conclude that dilemmas revealed in this study were a reflection of a gap between intentions and practice. In efforts to reduce these dilemmas we suggest methods with fairness in economic planning and priority setting, with concrete, official statements about the dominating views on which the priorities are based, and public information about these statements.

Older people's reasoning about age-related prioritization in health care.

The aim of this study was to describe the reasoning of people aged 60 years and over about prioritization in health care with regard to age and willingness to pay. Healthy people (n = 300) and people receiving continuous care and services (n = 146) who were between 60 and 101 years old were interviewed about their views on prioritization in health care. The transcribed interviews were analysed using manifest and latent qualitative content analysis. The participants' reasoning on prioritization embraced eight categories: feeling secure and confident in the health care system; being old means low priority; prioritization causes worries; using underhand means in order to be prioritized; prioritization as a necessity; being averse to anyone having precedence over others; having doubts about the distribution of resources; and buying treatment requires wealth.

Priority setting in mental health services.

This paper sets out an approach to priority setting in mental health services, built around programme budgeting and marginal analysis (PBMA). The paper also discusses the question of building in equity, especially the concept of vertical equity which, given the relative neglect of mental health services when resources have been allocated in the past, might serve as a mechanism for redressing the imbalance in resource allocation to the mentally ill. Beyond that the importance of eliciting community values to aid priority setting in mental health services is highlighted, particularly with respect to the principles underlying the mental health services or what one might call 'the nature of the good' that society wants from its mental health services. While it can be argued that trying to ascertain these principles or the nature of the good applies in all health services--and that is not disputed here--in mental health there is yet more need for clarification than in many other, indeed most other, health services. The need to exercise value judgments is emphasised. There is also a word of caution on the dangers of over-reliance on waiting for perfect evidence. Finally the paper considers how best to operationalise priority setting in mental health services, and perhaps make it less of a nightmare for mental health service planners than it currently seems to be.